Documentation

A complete medical record is beneficial for both the patient and physician because good documentation facilitates further care by others and helps demonstrate the physician's attention to detail should medical-legal difficulties arise.

Does the patient's medical record capture both the temporal course of care, including reassessments, and the progression of your diagnostic reasoning?

Have you sufficiently documented the following in the medical record?

patient identification

the date, and if important, the time of the assessment

pertinent positive and negative history and risk factors

relevant positive and negative physical findings

differential diagnoses or the diagnosis

diagnostic testing decisions

treatment plan

consent discussions

discussions with consultants

patient discharge and follow-up instructions

your signature and level of training

The rationale for your diagnosis and treatment plan should be evident in the documentation. When indicated, perform a reassessment and add this to the medical record.

Ask yourself whether another clinician would understand how you reached your diagnosis and whether you documented sufficient detail about your treatment plan.

It is always easier to obtain peer expert support when a differential diagnosis has been documented and pursued if reasonable to do so, or where appropriate, a serious diagnosis was considered and the reasons for ruling it out were documented.

It is important to note in the medical record not only when the patient has problems, but also when the patient is doing well, as this helps track the patient's recovery. This is particularly true post-operatively.